PACE Advanced Practice Registered Nurse

Job Description

PACE Advanced Practice Registered Nurse

Provide primary medical management in collaboration with the PACE physician(s) and/or Interdisciplinary Team. Conduct initial, semi-annual, and unscheduled assessments and reassessments; perform additional physical assessments of participants as needed; participate in the development and implementation of participant plans of care as a member of the IDT (Interdisciplinary Team). Evaluate participant physical complaint and provide appropriate treatment. Educate participants and families as needed regarding self-care and specific medical conditions. Function as a member of the interdisciplinary team. Provide daily oversight of the PACE Place Clinic. Perform rounds in the PACE Place contracted institutional home facilities (Assisted Living and Long-term Care Facilities). Regularly inform the interdisciplinary team of the medical condition of each participant, remaining alert to pertinent input from other team members, participants, and caregivers. Document care in the participant’s medical record consistent with documentation policies.

Duties and Responsibilities:

  • Provide primary medical coverage and collaborate with PACE Place physician(s) as needed.
  • Conduct initial, semi-annual, and unscheduled assessments, and reassessments and perform additional physical assessments of participants as needed.
  • Participate in the development and implementation of participant plans of care as part of and in collaboration with the interdisciplinary team.
  • Function as a member of the interdisciplinary team. Maintains regular attendance and participate in interdisciplinary team meetings; communicate participant changes, collaborate on care planning decisions and coordination of 24-hour care delivery.
  • Integrate the primary care treatment plan into the Plan of Care developed in collaboration with IDT (Interdisciplinary Team).
  • Interact with team members to meet emergent and acute needs of participants.
  • Participate in discharge planning for acute and long-term placement.
  • Evaluate and treat participants during acute illness. Manage participants’ chronic illnesses and conditions in collaboration with the physician(s).
  • Refer participants to medical specialists.
  • Manage care of participants in the nursing home making regular visits as dictated by PACE Place standards and participant need.
  • Provide preventive health care and maintenance for participants, including immunizations, screenings and monitoring of pertinent indicators and follow the PACE Place’s clinical protocols.
  • Prudently prescribe medications, therapies, and other treatments for participants.
  • Refer participants to medical specialists as indicated.
  • May be required to work non-standard hours including nights, weekends, and holidays as need dictate.
  • Make hospital or home visits as needed.
  • Work with Medical Director and Clinic Supervisor to formulate clinical policies, procedures, and standards of care.
  • Assist with the development of standards of care; perform on-going monitoring and evaluation of patient care practice and service delivery; provide guidance and training to staff regarding medical and quality assurance issues.
  • Advise the Medical Director and Primary Care Physician(s) in ways and means to establish better accountability of services to participants and referral sources.
  • Keep Executive Director, Clinical Manager, and Medical Director informed of needed material and Human Resources as program expands.
  • Act as a resource during intake of new participants and in the day-to-day operation of the center programs and as a resource for patient safety.
  • Provide teaching, training, and clinical support to staff.
  • Assume responsibility for professional activities and growth. Maintains professional affiliations and any required certifications. Keep abreast of current nursing knowledge, especially in the field of geriatrics by attending professional seminars and conferences.
  • Participate in staff meetings and monthly in-service meetings.
  • Participate in peer review with Medical Group.
  • Champion necessary and continuous changes to improve quality of clinical services.
  • Take it upon self to educate others related to policies and procedures when non-compliance is observed.
  • Anticipate problems and acts to avoid the escalation of problems.
  • Follow all Policies and Procedures and Occupational Safety and Health Administration (OSHA) safety guidelines.
  • Protect privacy and maintain confidentiality of all company procedures and information about employees, participants, and families.
  • Practice standard precautions and follow organization’s established infection control procedures.
  • Participate in and support the Quality Improvement initiatives.
  • Perform other duties as required or requested.
  • First Aid and CPR certification is important but not mandatory.
  • Other job duties, as assigned.


  • Graduate of an accredited school of nursing.
  • RN State License
  • APN License – Florida Board of Nursing.
  • Certification as a Nurse Practitioner with prescriptive authority.
  • Current driver’s license, proof of insurance and means of transportation.

Experience: Minimum of 2 years working with the frail or elderly.

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PACE Partners of NE FL

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